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ONLINE

(Partial list)

Email Virus Hits Major US firms | Go To Article

Facing Down the Downturn | Go To Article

Keeping Kids Safe on the Internet: Parent Power! | Go To Article

A Call For Help:
Employee-assistance programs flourish in tough times | Go To Article

Mentors of the Mind
Men who wouldn't go anywhere near traditional therapy seem more willing
to accept short-term career and personal guidance from 'coaches'. | Go To Article

The Independent Practitioner
A Funny Thing Happened on the Way to Summer Vacation. | Go To Article

IN-PRINT

BRIEFINGS

Psychologist Beware—Managed Care Revisited
Summer 2004 | Go To Article

“Law and Order” and September 11th
January 2002 | Go To Article

When is it All Right to Say No
July/August 2004 | Go To Article

“Original ideas:
Internet 0
Humanity 1,000,000,000,000,000”
November/ December 2000 | Go To Article

TALK TO AN EXPERT, FOR $19.95
Sept./Oct. 2000 | Go To Article

A Special Thing Happened on the Way to Writing this Article
September/October 2007 | Go To Article

Confessions of a Recovering Managed Care Provider
March/April 2005 | Go To Article

Alice in HIPAA Land
July/August 2003 | Go To Article

Reality TV and the New Breed of Patient
May/June 2003 | Go To Article

Meeting with Vice President Al Gore
December 2000 | Go To Article

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::articles

Kournikova’s Love
Latest Virus Hits Dozens of Firms
By Sascha Segan

Feb. 12, 2001
Why Anna Kournikova?
Like the ninth-ranked female tennis star herself, the virus using her name is more provocative than destructive.

Using the tennis star who turns more heads with her physique than her backhand is a blatant attempt to appeal to libido, according to psychologists and virus chasers alike. With her name attached to a JPEG file, it is no wonder the virus spread so quickly, according to virus experts.

Kounikova, who has never won a major tennis tournament, just surpassed hunky basketball star Michael Jordan as the most downloaded athlete on the Web.

"She's a very popular athlete who has never won a major tournament but all her matches are watched and very popular," said James Thomas of Trend Micro. "She is beautiful."

One psychologist speculated that an obsessed fan may be the culprit.

"If you attach a provocative name or words to an e-mail, the perpetrator thinks people will be more likely to open it," said Richard Sherman, a Los Angeles-based psychologist.

But who would do such a thing?

"It's the idea of the crazed and obsessed fan," said Sherman. "When someone is obsessed they feel a kind of unrequited love that they want to broadcast."

Like the ILOVEYOU virus, Sherman said the opportunity to receive a photo of the tennis star was as enticing as receiving love last year. What better time to get a JPEG of a pretty, young tennis star than around Valentine's Day?

In fact, the 18 to 35-year-old male group is very much aware of the tennis star with the great legs, said Robert Hermeryck of Trend Micro.

"She is gorgeous" said Hermeryck of antiviral firm Trend Micro. "She's beautiful. Men and women alike want to look at her."

Viruses spread by provoking their targets, according to Sherman. Sometimes out of a feeling of powerlessness, virus creators use words that may scare potential victims. Sometimes, out of obsession they use a celebrity name.

"They are trying to connect to people in one way or another," he said. "With the ILOVEYOU, it was a sick trick as a way to seduce people. With Anna Kournikova it is a kind of admission of their love, unrequited. But with people who have personality disorders it could be a multitude of reasons."
— Rose Palazzolo

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Facing Down the Downturn
The R-Word Can Terrify, But Psychologists Say People Are Resilient
By Robin Eisner

N E W Y O R K, Jan. 11, 2001 — With a son in law school and a daughter in college, 54-year-old Frank Stevens, believes his professional life is about to unravel.

Stevens, a salesman in the high-tech sector, senses that the consulting company he works for is going to shut down, unable to compete in the tightening economy.

Although the 6-month-old Southern California firm is a subsidiary of a major company in the Midwest, Stevens — who asked that his real name not be used — says the start-up satellite business doesn't have the marketing or advertising dollars from the company necessary to grow.

"They don't have money," says Stevens, who sells the company's computer networking services. "They are cutting back."

He took the job, after 20 years at another major corporation, because of the high salary and the bracing challenge. Now, he has withdrawn $40,000 from his seven-figure savings, because the sales commissions he depended on have dried up. He is selling real estate to pay off debt. And he's looking for a new job.

Changing Times
One day it's Sears, Roebuck & Co. cutting thousands of jobs. Then, it's Rupert Murdoch "consolidating" the Fox News online division, where hundreds were handed pink slips. After almost a decade of growth, an economic slowdown appears to be coming to both traditional and new-economy businesses in the United States. Although the unemployment figures are still very low, there's instability, signs of possible turmoil and worry.

Most Americans don't save money, let alone prepare for financial doldrums. But soon they may have to adjust to a shrinking economy with fewer jobs and less disposable income. For some people it will be déjà vu all over again, reliving the 1982 and 1991 downturns, which eventually reversed. For younger workers used to moving around freely, it may be their first experience of shrinking opportunity.

While such conditions could initially discourage and depress people, psychologists with expertise in financial issues say it's not all doom and gloom: Business cycles are inevitable, and dips help society return to core values of family, friends and community. Eventually, philanthropy, banding together and frugality become fashionable in lean times, as consumerism was trendy in booms.

Economists tell us the economy is slowing down, but not quite as badly as prior downturns of the past two decades, when growth lingered at 1.5 percent. The Commerce Department, in its latest figures, reports the third quarter U.S. gross domestic product last year was only 2.2 percent. That's down sharply from a 5.6 percent rate set in the second quarter, and is the slowest growth in four years.

Still, don't start using the R-word — we're not experiencing a recession, which is defined as two consecutive quarters with negative economic growth.

Setting Priorities
At times like these, psychologists say the most important thing is not to panic. People need to take a realistic look at their finances and consider the worst.

"When money starts getting tighter, people have to start looking at their budgets and determine what they can do without," says Maurice Elvekrog, a psychologist and chartered financial analyst from Bloomfield Hills, Mich. "Parents should talk to their children about economizing, explaining that they may have to do without some things but that the family will remain together and manage."

Back in California, Stevens forewarned his children during Christmas about his situation. "I spoke to them honestly," he says. "They are old enough not to have to be shielded from life." Tuition for the kids will still be met, but gift giving will be curtailed, Stevens told the family in a pre-Christmas gathering.

Americans may also need to reconsider what is important to them, that having the latest consumer gadget may not be so significant. "People may have to shop differently and try to find value in relationships and personal activities that do not cost anything," says Richard Sherman, a clinical psychologist in Tarzana, Calif. who works with large companies advising them on downsizing.

People may want to consider a downturn an opportunity to make a career change. Stevens says he is considering living on his retirement money and settling for less income in another profession. "I always wanted to be a teacher," he says.

The Meaning of Money
Psychologists acknowledge that loss of money can be difficult because our society associates love, power and freedom with money. And since people define themselves so much by their jobs, a job loss — or even the fear of losing one's job — can threaten their very sense of identity and self-worth.

James Gottfursht, a psychologist specializing in money and employment issues from Los Angeles, suggests people take small steps to adjust to changing times, cutting back, say, on the number of videos they rent a week or the number of times they eat dinner out. "Smaller losses are easier to face," Gottfursht says.

As people have less, thriftiness will become "chic," as it has in past times, Gottfursht says. "Instead of conversations about spending, discussions might veer towards spending less money on dinners or vacations," he says. "Once people break free of the addiction to money, they realize that they really didn't need it so much."

Facing Loss
If you hit a crisis, like losing your job, you will be grateful for re-cultivating your friends and family, who can help you through it. "The worst thing you can do is isolate yourself," says Sherman. "Exercise and eating right is as important now so you don't get depressed."

Keeping perspective also is key. "You may have lost a job, you didn't lose an arm," says Neil Lewis, a psychologist in Marietta, Ga., who advises companies about downsizing.

Lewis advises the recently unemployed to "take stock, take charge and take action": First, look at cash flow. Then, take responsibility, and don't blame others (or yourself) for your situation.

"Instead, they should take action and make looking for a new job, a full-time job," Lewis says. People should talk to friends and associates, and join support groups to talk to others who may be going through the same thing.

Human beings have amazing recuperative powers, and will manage, says Lewis. "Unfortunately, life sometimes is not easy," he adds.

The Survivors
The person who receives a pink slip, however, is not the only one who suffers, the experts say. If a company keeps cutting its staff, those who remain often pick up the additional work to a point of what can be diminishing returns, says Mitchell Marks, a psychologist who specializes in businesses from San Francisco.

"People may be willing to run the treadmill and work hard if there are bonuses and rewards at the end," Marks says. "But for fewer benefits, people may decide to slow down."

With a possibility of increased unemployment, it also becomes difficult for people to find new jobs, should they want to jump ship. Young people used to ever expanding prospects may get resentful.
Managers will have to find ways to motivate remaining employees to increase output if raises and other perks become less likely. "Managers should be proactive and communicate with employees that they may have to work harder now with the hope that prosperity will return and so they do not lose their job," Gottfursht says.

Should sluggishness continue, though, the have-nots may start getting angrier with the haves. "There is a growing divide among the rich and poor," Marks says. "When things are rosier, Middle America didn't begrudge the haves. But in a tightened economy, the middle class may not be able to tolerate the high salaries of CEOs and athletes."

Frank Stevens takes antidepressants and sees a psychologist to help him cope. He is optimistic he will find another job, after being to three job interviews recently. "I am a salesman," Stevens says. "I am not afraid to sell myself about how good a worker I have been … If I could do it for someone else, I could do it for a new employer."

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Keeping Kids Safe on the Internet: Parent Power!
By Natalie Walker Whitlock and Marilyn Martinez

Now for the good news: Parents have more choices and tools than ever before to help keep their families safe online. They can stock a technology toolbox, full of filtering, blocking, monitoring and tracking software. They can use the parental controls included with their ISP or online service and can use only kid-friendly search engines and portals to limit children’s exposure to inappropriate sites.

“I’m all in favor of a kid’s invasion of privacy because of the danger potential here,” says child development professor Polland. “You cannot take the chance. Because kids feel so safe and so bright and so confident about how to beat the system, they are in danger.”

Some parents share an online account and password with their child to keep tabs on their children’s e-mails with online friends. Parents can even track chats and instant messages in real time, even when they are away from home. There are also non-tech options such as creating a Family Internet Use Contract (www.safekids.com/contract.htm ) Which options you use depends on your child and your own parenting style.

But while technology has provided parents with numerous options, high-tech safety tools should be only a piece of the solution – not the whole pie. Indeed, experts repeatedly caution against relying solely on high-tech babysitters to keep kids safe online. “Technology is not a replacement for good parenting,” says America Online chairman Steve Case.

O’Connell-Jay, who now educates parents, teachers and police on the subject of Internet safety, recommends that parents get involved in their children’s Internet life – even ask their kids for lessons if they’re computer illiterate. In her sister’s case, “Nobody knew, because nobody was computer literate,” she says.

The key to keeping kids safe on the Internet today is parents who recognize the possible dangers, understand the technology, and take the time to be involved in their child’s online activities.

“Parents who understand the Internet and monitor the time that a child spends online offer the best protection,” says Richard Sherman, Ph.D, a psychologist specializing in children and Internet issues. “Kids need appropriate monitoring by parents at home to prevent inappropriate behavior online."

Natalie Walker Whitlock is the author of A Parent’s Guide to the Internet (Parent’s Guide Press, 2003). Marilyn Martinez is the associate editor of L.A. Parent magazine, a United Parenting Publication.

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VITAL SIGNS
A call for help
Employee-assistance programs flourish in tough times

By Kristen Gerencher, CBS.MarketWatch.com
Last Update: 12:02 AM ET March 27, 2003

SAN FRANCISCO (CBS.MW) - After a long, frustrating search for a psychotherapist in her health plan, Laura Walker found an available counselor through an unlikely source - her mother's employee-assistance program.

Because the EAP covered immediate family members, Walker achieved through a single phone call what two-weeks of cold calls failed to produce: A list of doctors taking new patients who would accept her health insurance.

"I felt like the situation was hopeless," says Walker, 25, upon being turned away by numerous therapists. After answering a few questions to assess her need and preferences, the EAP found a match within a day or two. "It got me an appointment I wasn't able to get myself."
Once known as a first stop for treating workers' drug and alcohol abuse, EAPs now provide a host of resource and referral services to people who otherwise would take care of their sundry problems on the boss' watch. And unlike a health plan, many EAPs offer counseling sessions for free, with no co-pay or deductible acting as a disincentive.

The programs can provide a one-stop shop or neutral third-party analysis to workers in distress, whether they're dealing with divorce, a troubled teenager, ballooning debt or an elderly relative's decline.
Most people self-refer to the programs, which often function as "derailment prevention" for employees slipping at work, says Richard Sherman, a clinical psychologist and EAP consultant in Tarzana, Calif.
"It helps keep good employees functioning well on the job," Sherman says. Employers "want to prevent the employee from going off the positive course for the benefit of the company."


Guarding productivity

Despite widespread belt-tightening, employers aren't doing away with the benefit, analysts say.
In fact, as the economic slump drags on and the war with Iraq heightens anxieties, EAPs appear to be living up to their promise of keeping workers productive and providing them with alternative solutions to problems that distract them.

In 2002, 71 percent of large employers offered an EAP, up from 64 percent in 1998, according to Mercer Human Resource Consulting. Last year, 14 percent of small employers with 10 to 499 employees extended the benefit, up from 12 percent five years ago.

The vast majority of companies offer screening and referral with short-term counseling, with screening and referral-only programs the next most popular choice. The remaining employers opt for a phone-based program.

EAPs often complement health plans and are "something employers are really striving to maintain and promote," says Kate Sullivan, health-care policy director at the U.S. Chamber of Commerce. "They're almost always offered separately and apart from the health plan so employees not involved in the health plan can have access."

Many companies placed a "a renewed sense of importance" on EAPs after September 11, says Richard Chaifetz, chief executive of ComPsych, a Chicago-based consulting firm and EAP provider that covers 7 million Americans. Calls for help jumped 15 percent last week when the war with Iraq began, but have since leveled off.

"There's a huge return on investment in terms of productivity, performance and absenteeism," Chaifetz says. "The amount of money employers pay to get an EAP typically returns three to five to 10 times as much in terms of measured savings in the first year."


User-friendly coverage

Employers contract for different packages, with most opting for a plan covering mental health, legal and financial services and work/life services such as child and elder care, Chaifetz says. Some programs provide unlimited financial and legal counseling.

Typically, help is available at any time, seven days a week and begins either online or with an 800 number, he says. About 4 to 6 percent of eligible employees take advantage of their EAPs on average, and most seek help with relationship and family issues.

What's more, the programs often allow a certain number of visits per incident as opposed to limiting access more generally, Chaifetz says.

"If someone calls in for a divorce issue and three months later calls in for a child who's not doing well in school, that would start the clock again."


Confidentiality and mental health

Though companies generally strive to get 5 to 10 percent of their workers to use their EAP, many employees are afraid to make contact because of confidentiality concerns, says Tom Billet, a senior consultant at Watson Wyatt.

But EAP providers only report the number of employees who use the service back to the employer and not names or details, he says.

"You call the EAP provider and no one at the company ever knows you call," Billet says. "Confidentiality is what they live and die by. If it at all came out that they were releasing names to employers, they'd be out of business pretty quickly."

EAPs, which have seen rising education levels among their providers over the years, are particularly useful for those seeking mental health advice, Sherman says.

"It sometimes takes the stigma away that some people have toward going for psychological help," he says.

Unlike other types of health care, most people don't have a long-standing counselor in their portfolio of doctors and may feel embarrassed or overwhelmed when searching for one, Billet says.

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Monday, June 18, 2001 | LOS ANGELES TIMES

Mentors of the Mind
Men who wouldn't go anywhere near traditional therapy seem more willing to accept short-term career and personal guidance from 'coaches.'

By BENEDICT CAREY, Times Health Writer

You don't have to get in touch with your feelings: You can manage them. And instead of plunging into self-analysis, you can concentrate on innocent-sounding things such as emotional intelligence, better relationship-management skills and a more successful personal style.

What regular guy would consult a therapist when he can have . . . a coach?
Though most men are still very reluctant to seek traditional, one-on-one therapy, more and more of them are now consulting professionals who call themselves life or career coaches, psychologists say. Coaching is not the same thing as therapy, experts agree. One is an open-ended exploration of the origins of emotional makeup; the other is usually short-term and focused on achieving concrete goals, often in the context of career.

But the number of experienced therapists who now consult as coaches has at least doubled in recent years, psychologists estimate, and they are exposing more men than ever to the benefits of psychological self-evaluation.

"The very word 'coaching' is appealing to people, especially men, and allows them to access basic psychological principles in a way that's socially acceptable," says psychologist Bertram Edelstein, who runs an executive coaching practice, the Edelstein Group, in La Jolla.

"You begin talking about work, and that's the one place where most men feel competent, or at least comfortable," says Richard Sherman, a psychologist in Tarzana who does coaching and runs his own clinical practice. "And at some point you begin to ask about work-life balance, and that acts as a bridge into the personal life."

Steve Finden, a 36-year-old insurance company executive living in Encinitas, began consulting with Edelstein about three years ago as part of a company-sponsored effort to improve teamwork. Finden describes himself back then as "a typical guy, pretty wrapped up in myself, and in my work," and hardly the type to seek individual psychotherapy.

After taking a personality test and reviewing reports of how others perceived him, Finden got a lesson in self-awareness, he says. "I thought I was an effective strategic thinker, a good communicator," he says. "It turned out I was about the only one who thought so."

Part of the problem was that others didn't think that Finden passionately believed in what he was saying. That apparently superficial observation got him thinking more deeply about what shaped his personality. "You can't help but think about where your habits and style come from, how you got that way, and how you come across at home," he says.

Often enough, Edelstein says, people trace their personal style at work back to their family of origin, and sometimes even back to some defining crisis, such as losing a parent, the illness of a sibling or an alcoholic parent. And when it's effective, says Edelstein, career or life coaching induces changes that usually move from the person's work life into their private life. "Nine times out of 10 times I hear from the spouse that the side effect from coaching is improved personal relations at home," he says. Men in particular are more likely to respond to advice when it concerns their effectiveness or promotability. "Their spouse could have been saying the same thing for years and they ignored it," he says.
"We weren't having problems to start with," says Finden's wife, Elizabeth, "but I would say that now that he's managing people and he's learning to work with them, he's become more present, a better listener, less concentrated on himself."

* * *
Analysts attribute therapists' move into coaching to two phenomena: managed care, which has put a squeeze on longer-term psychotherapy; and the growth of Internet and tech companies in the 1990s, which happened so quickly that employees and managers had to learn social and management skills on the fly. "These are the IT types who are accustomed to working by themselves, alone in a room, and suddenly they're managing 500 people and they know nothing about human dynamics," says Steven Berglas, a psychologist and author who has an executive consulting practice in Marina del Rey.
The technology itself has changed the way people relate to one another, Sherman says. "I'm now dealing with employees with virtual offices seven days a week--cell phones, faxes, computers, Palm Pilots--and part of what I try to do is help them not lose sight of their other life, their family and friends."

And by and large, these are not men who seek solutions on the couch, despite the popularity of shows such as "The Sopranos," in which mob guy Tony Soprano regularly confers with a therapist. Overall, men account for only about a third of all people seeking some kind of individual psychological attention, psychologists say, which is not much different from a decade ago.

"The problem is that therapy itself is antithetical to everything it is to be a male in this society," says Rob Pasick, a psychologist who teaches in the business school at the University of Michigan. He co-edited a 1990 book called "Men in Therapy" that helped fuel a surge of interest in men's issues. "Asking for help, showing weakness, admitting you have no control, revealing yourself to a stranger--these just aren't things guys are taught how to do."

So it is that therapists-as-coaches are now resolving personality problems--of ego, temper, anxiety, fear of failure--for people they otherwise would never see, most of them male. If Tony Soprano is altering the perception of psychological help in the popular culture, they say, then life and career counseling is doing the same in practice, in men's work and home lives.

Glenn Good, a psychologist at the University of Missouri who has written a guide to counseling males, says the growth in coaching represents a broader trend that is bringing psychological services to men in more accessible ways. "We've learned, for example, that traditional men's men will talk about their personal lives, but they're more likely to do so in a seminar, or in a career context" than a traditional psychotherapy setting.

* * *
For all that, psychotherapists still have some strong reservations about life or career coaching. For one thing, the field has no widely accepted professional standards; the International Coach Federation, a professional organization in Washington, D.C., estimates that there are more than 10,000 people calling themselves coaches, and only about 600 of those have completed the Federation's certification process. The Federation's Web site (http://www.coachfederation.org/) allows individuals or companies to search for certified coaches in their area.

Another risk is overtreatment--therapists luring clients into longer-term psychotherapy who may not need it or want it. "In coaching, the biggest danger is that you don't let go when the behavior you're hired to treat goes away," says Berglas. "Once the problem is solved, your job is done; that's it."
Finally, life or career coaching can never be a substitute for psychotherapy. There are many men whose problems go deeper than any occupational personality test, and trying to "coach" them through it is irresponsible, psychologists say.

Craig Paxton, a 34-year-old Web designer living near Ann Arbor, Mich., ended up in Pasick's care after a job ended badly. He was losing his faith that he'd ever find work again. "Confidence was becoming a huge problem," Paxton says. "It didn't matter how much people would tell me how good a job I was doing; I still saw the flaws."

But further discussion revealed that Paxton's anxieties ran deeper, and were partly related to the suicide of a good friend. He showed signs of depression as well.

Paxton was referred to regular therapy and now attends a men's therapy group. "I just don't understand the stigma that therapy has for men anymore," he says. "You've got to support the world on your shoulders, and you can't ask for help? If I can do it, anybody can."

Psychologists say that, whatever its limits, the arrival of psychology in the context of life and career goals has at least tipped off many men to what therapy can offer. Says Finden, "I've figured out about as much as I want to know at this point, and I think it's had a nice spillover effect on my personal life. You'd need to go much deeper to understand everything. But at least I know it's there."

Copyright © 2001 Los Angeles Times
For information about reprinting this article, go to http://www.lats.com/rights/register.htm

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The Independent Practitioner

APA Division 42, Fall 2000

A Not So Funny Thing Happened to Me on the Way to Summer Vacation

(The following is a true account of one psychologist’s recent, somewhat alarming experience with a major managed care company. Only the names have been changed.)

As I anticipated writing an article for the summer edition of The Los Angeles Psychologist, I thought that this would finally be the time where I could collect my thoughts and write a somewhat lighthearted piece in keeping with our childhood recollections regarding this time of the year. That was until Dr. R. recounted to me his hair-raising encounter with a large mental health managed care company. I thought that his story was so important to many of us in our profession that it was worth retelling in its entirety.
Dr. R. is a psychologist who has been in clinical practice for over twenty years. He has a successful practice, which includes both managed care and fee for service patients. He also does some consulting. In addition, he has been an active member of a number of professional organizations and has assumed various leadership positions. Further, over the years he has served as an oral examiner for the licensing of new California psychologists and has been a provider member from the community on a number of credentialing/peer review/quality improvement committees for different managed care companies. In addition, through Continuing Education programs, readings and consultations, he has worked hard to keep up with changes in the law, ethics, record keeping, and community standards as they relate to the practice of psychology. Dr. R. typifies the many well trained, quality psychologists that make up our profession at both the state and local levels.

This is why Dr. R. was quite surprised and alarmed when he recently received an overnight letter from the Director of Provider Operations for a large managed care company, one for which Dr. R. has always served in good standing since joining that panel in 1989. The letter in part stated that, while this particular organization had appreciated his participation in its panel, “after careful review” the Credentialing Committee had decided to terminate his membership in the network “due to a low client satisfaction rating.” Termination was to occur 90 days from the date of the letter. This would allow the provider to complete the treatment of “covered members” or to “contact a case manager…to discuss transition options.” Further Dr. R. was entitled to a “one-time” review of the decision by a medical director as long as this review was requested within 30 days of receipt of the letter.

Dr. R. described his panic as he read the letter. At one point, patients from that managed care company had made up more than 20% of his practice. He knew of no ethical code violations in his practice of psychology. This particular managed care company periodically would send profiles of a provider’s performance. Dr. R did remember that when he attended one of this company’s recent training programs, the presenter had indicated that very few patients ever respond to patient satisfaction surveys. Nonetheless, his scores had always been in the acceptable range, including the most recent one dated December 1998. In fact, the scheduling time between a patient’s first call to his office and an initial appointment averaged only 5 days while that company’s standard for non-urgent sessions had been 14 days. Further, Dr. R. recalled easily passing a site visit which this company had conducted in the summer of 1999.

Immediately, Dr. R. called the person whose name was on the letter. To his dismay, the assistant told him that the Director of Provider Operations was out of town for the next two weeks. The assistant went on to tell Dr. R. “that’s okay because this will give you more time to prepare your defense.” Dr. R. was incredulous and questioned, “What defense? I don’t know what if anything I did wrong given that there was no supporting documentation in the termination letter.” The assistant responded, “We’re sorry but we don’t have that information here.” Dr. R. quickly realized that he was talking to someone who, while she may have been well intentioned, was merely a clerk who had no power whatsoever in this matter. Despite several calls to that office, she was unable to give Dr. R. the name of anyone who might be in authority to shed any light on this matter.

According to Dr. R. the situation went from bad to worse. He had previously liked being a member of that panel for several reasons including that from time to time many of his old patients would request to see him again, even four or five years later, as new problems emerged in their lives. It was only one week later that such an old patient informed Dr. R. that when she had called the managed care company to request authorization to see him, she was told that this was not possible since he was being removed from the provider panel. No reason was given to the patient.

At that point, Dr. R. became even more concerned since he recalled that on many hospital privilege forms and other organization applications, there is a question which states, “Have you ever resigned or been asked to resign from the staff of any hospital or organization because of problems regarding privileges, credentials, or unprofessional conduct?” Dr. R wondered whether being involuntarily removed from a managed care company would fall into this category and haunt him for years to come.

Because Dr. R. had had some experience with other managed care companies and related organizations, he was determined to assertively follow through, to determine if there had been a mistake made, or to see if he had inadvertently done anything wrong to warrant this type of action. He talked to an attorney from the Legal and Regulatory Affairs Office of the APA Practice Directorate. She indicated that most of the contracts between many managed care companies and psychologists are one sided because a provider can easily be removed in thirty days “without cause.” She indicated to Dr. R. that if he were really serious about pursuing this, he might have to hire an attorney and incur the necessary expenses.

As the time passed, Dr. R. became even more frustrated and worried. He still did not know what he supposedly had done wrong, if anything. In his involvement with committees from other managed care companies, he knew that before a provider is ever dropped “with cause” from those panels, he or she is notified and given great detail regarding what the problems or issues are and what corrective measures can be taken. Dismissal from the provider panel is reserved for the most egregious infractions. Mentally, Dr. R. kept reviewing a fraction of the possibly hundreds of cases that he had seen for this particular company over the years. Nothing even remotely negative stood out. He even recalled a conversation that took place a few weeks earlier with a senior psychologist from this managed care company in which she had been very positive towards his work as she then referred him a difficult case.

Given that Dr. R. was getting no response by going through proper administrative channels, he decided to try to communicate directly with both the local and national medical directors of this managed care organization. He was quite pleased with the reception that he received. In fact, one of these senior psychiatrists actually took it upon himself to review the case and be the one to present the “findings” to the credentialing committee.

What the medical director found was quite disturbing. First, he indicated “the manner in which Dr. R. had been informed without means of redress” had been wrong at least in his “humble opinion.” What was equally troubling was that the alleged “complaints” against Dr. R, for which he almost been cavalierly dropped from the panel, should not have ever gotten to that stage in the first place.

What was the nature of the complaints that so jeopardized Dr. R.’s chances of being retained by this panel? One must remember that Dr. R. was being considered for recredentialing in 2000 and had successfully gone through the credentials committee process every two or three years since his initial acceptance to that panel. First, in 1996, a prospective patient had complained that she had tried unsuccessfully to contact Dr. R. to make a first appointment and that he had never called her back. Dr. R. questioned this since he has a secretary and together they have a good track record of returning all calls in a timely manner. Dr. R. even wondered if the patient had actually had the correct phone number, but four years later and not knowing the name of the patient, it certainly would be impossible to track this down. So much for serious complaint number one.

The second complaint was even more illusory and had nothing to do with actual patient satisfaction but with treatment planning and recommendations. It was even more peculiar how this generated any flack whatsoever. Dr. R. briefly saw a depressed patient in 1993 who, up until one month prior to the start of treatment, had been abusing cocaine. Dr. R. recommended to the patient that he attend frequent 12 step CA meetings along with individual psychotherapy. In 1996, when the managed care company had an outside EAP reviewer apparently look over various clinicians’ treatment plans, he determined that this patient should have been referred to either an inpatient drug rehab facility or a structured outpatient program. The reviewer who did not see Dr. R.’s records, but only a very brief structured treatment plan form, could not have had enough information to disagree with the clinician’s findings. Further, the medical director agreed fully with Dr. R.’s recommendations, not the reviewer’s. Parenthetically, Dr. R. holds an APA Certificate in Proficiency in Alcohol and Psychoactive Substance Disorders. If anyone at the managed care company had any concerns about his approach to treatment, why hadn’t someone ever called him to discuss this? What is even more troubling was that this was a case from 1993 being used to affect the provider status of a psychologist in 2000, seven years later.

Dr. R. waited anxiously until the next credentials committee meeting. Finally, he received word from the corporate medical director, who informed him that the committee had voted to retain him on the provider panel and to immediately lift the suspension on referrals. This suspension should never have occurred in the first place. He also indicated that the medical director who had presented the review had advocated “energetically” for Dr. R.

What can we learn from Dr. R.’s experience?

First, it is important to recognize that the managed care companies do have on their staff some decent and wonderful professionals, including psychologists and psychiatrists, who believe in the quality of patient care, are psychologist friendly, and want providers to be treated fairly. However, we also must remember that huge consolidated corporations are currently controlling the mental health coverage of millions of patients. Further, important administrative decisions may sometimes be made almost independently of the clinical staff that they have employed. There has to be something seriously wrong for a company to even consider the removal of providers for essentially no valid reasons. One can only speculate on the possible rationale for such a decision—the wish to decrease the size of the network or the desire to eliminate those psychologists who under older contracts may be receiving a slightly higher reimbursement rate than newer providers. Dr. R. has had years of experience in working with insurance companies and as a result, was able to mobilize a concerted effort to retain his provider status. My concern is for those psychologists who may be excellent clinicians but less familiar with the system. I will leave to the readers of this column to draw your own conclusions.

Given this, it is incumbent upon psychologists to interact with these companies from both a good professional and business sense. For instance, one should consider periodically checking on the existence of any possible patient complaints just as, in our personal lives, we may need to check periodically on the status of our credit rating. The time to do this is not when one is about to be recredentialled. One may also want to consider having an attorney review new contracts with such companies, in advance of resigning.

And of course, it is important as psychologists that we diversify so that we are not beholden to any one managed care company. Further, the more one can expand our professional psychologist repertoire and become more expert in specialized areas, we will be successful independent of any organization.
By the way, some of you may be wondering how I knew so many of the details of Dr. R.’s struggle with that particular managed care company. That is because I actually am Dr. R. Now, I can go back and enjoy the rest of the season. I wish all of you and your families a pleasant, restful, and energy reviving summer.

Richard Sherman, Ph.D., is a psychologist in private practice in Tarzana, California. Dr. Sherman is the 2000 President of the Los Angeles County Psychological Association.

This article originally appeared in the July/August issue of The Los Angeles Psychologist and is being reprinted with permission.

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BRIEFINGS
Summer 2004

Psychologist Beware—Managed Care Revisited

I recently got a call from a large Managed Care company. “We want you to do an evaluation of one of our subscribers and we need this done right away,” the woman on the line stated. “We will give you up to three visits to do this.” She went on to state, “If you then want to see this patient for therapy, you just have to fill out the Outpatient Treatment Report. She indicated that the prospective patient had just been released from a short stint in jail and was having work and family problems. When I asked for more clarification such as why she had been incarcerated, given that I did not want someone who might have recently been violent coming to my office, without at least a little warning, she indicated that she could not disclose this information. When I asked how much I would be reimbursed for this evaluation, she curtly replied, “It’s in your contract.”

This call came at the right time because it gave me more reasons for resigning from most if not all of the managed care company panels. Like several of my colleagues, I had agreed to join these panels several years ago for a variety of reasons: (1) managed care was literally taking over Southern California with the perceived result that if one did not sign up, one might not have access to most patients, (2) by agreeing, along with many other psychologists, to participate and see patients for a discounted fee, hard working employees and their families would be able to get first-rate mental health care for, at most, a nominal co-pay, and (3) we were told that the managed care companies would pay in a timely manner with no bureaucratic red tape. How wrong these assumptions have proven to be. One point however does still hold some weight. I have several patients that I have seen off and on for an extended period. If I were to completely stop seeing them through their managed care plans, some would not be able to stay in treatment even at a reduced fee. Unfortunately, managed care continues to have a negative influence on the practice of psychotherapy, including some loss of control over clinical decisions, inappropriate or insufficient treatment allowed, additional, often needless paperwork, and a decline in revenue due to low reimbursement. Reimbursement rates do not take into account inflation with several plans holding fees at 1987 rates. According to the Bureau of Labor Statistics and taking into account inflation, a fee of $70 then is equivalent to $114.74 today—thus a net loss of almost $45 per hour for the psychologist. At the same time, the CEO’s of the largest healthcare insurance companies are making millions of dollars per year.

According to Yahoo Finance, for the fiscal year 2002 (including salary and bonuses), William McGuire, M.D., the Chairman and CEO of United Healthcare earned $9.4 million while Mr. Howard Phanstiel, Chairman, President and CEO of PacifiCare earned $3 million.

Whatever the managed care hourly rate that the psychologist earns is also somewhat deceptive given the additional minutes to hours that one has to spend related to the managed care created bureaucracy. A typical scenario of additional time that the psychologist (and/or support person) must spend is as follows:

Before the patient’s first visit:
• Call insurance company for authorization and verify mental health outpatient benefits (up to 15 minutes)
• Obtain the different reimbursement/co-pay schedules depending on whether the diagnosis will be parity or non-parity
• Assemble new patient information with forms specific for the individual insurance company (5 minutes)

After the patient’s visit:
• Document specific information that the insurance company is requesting which may be more in depth than is needed to effectively treat the patient (10 minutes)

Requesting additional visits:
• Prepare treatment plan (can be as brief as a couple of minutes or, if a detailed report is needed, as long as 30 minutes or more, depending on the insurance company)
• Talk to a care manager regarding the patient’s progress
(5 -15 minutes)

Billing and other administrative issues:
• Contact insurance company if payment has not been received in a timely manner (10-15 minutes)
• Analyze Explanation of Benefits to make sure that payment is correct (up to 5 minutes)
• If EOB is not correct, psychologist must spend time with insurance company to rectify any errors (15 minutes or more)
• Explain to the insurance company the difference between parity and non parity benefits and different payment schedules (5 -10 minutes)

While the psychologist is getting paid for a 45-50 minute session, at times, this clinician could actually spend approximately an additional 75 minutes or more of time that is not reimbursed. Further, this does not take into account the amount of time that the psychologist is placed on hold “for the next available representative”. This also does not consider the time that the psychologist has to spend if there is a random chart audit and all progress notes have to be photocopied and sent to the managed care company at the psychologist’s expense.

What then is a psychologist to do? New psychologists are especially tempted to join managed care panels as a way to more quickly build up a private practice. Other psychologists who have been on these panels for an extended period are often torn given that several of their patients are seemingly locked into the managed care system. Given the time spent, as outlined above, servicing the accounts of each patient along with the restrictions that most managed care companies place on the treatment of those patients, psychologists could better utilize time in professional networking and in gaining additional specialty training which should translate into increased referrals. Further, we need to support the advocacy efforts of our professional organizations at the local, state, and national levels.

Oh, you might wonder whatever happened to the woman from jail. I reluctantly agreed to see her for a one time evaluation but …….she never showed up for the appointment. I wonder if I can charge the managed care company for the No Show. I doubt it!

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BRIEFINGS
January 2002

“Law and Order” and September 11th

Prior to the September 11th attacks, in addition to listening to the news during the day, I used to watch the 11o’clock news—a wrap up of the day’s events before bed. Every night for the last several weeks, I find myself watching instead reruns of the crime program “Law and Order”. While the show may be somewhat formula-like in style and concept, I am intrigued by each episode nonetheless. More about my changed TV watching habits later.

On the morning of September 11th, 2001, I was in Washington, D.C. as part of a small group of Southern Californians who are members of a national political organization. We were in Washington for five days to meet with different representatives of the federal government. That Monday, the day before, we had a meeting with Attorney General Ashcroft. We also met with Deputy Defense Secretary Paul Wolfowitz at the Pentagon. Ironically, less than twenty-fours hours before the attacks, we had even had a working lunch with two noted anti-terrorist experts who complained that our government was not doing enough to protect the country from possible terrorist assaults. The organizer of the conference, as a way to encourage participation, kept talking in advance that this was going to be an unforgettable trip. He was so right for what obviously became the wrong reasons.

That Tuesday morning in Washington was absolutely a glorious day –sunny, clear, and cool. One of those picture post card days. Our first stop was the Capitol. We had heard on the way over that there had been an accident at the World Trade Center and a vague account that a plane had struck one of the towers. We had some concern but most of us visualized a small plane accident, nothing more. We proceeded into the Capitol rotunda, greeted by an aide. We were to meet with a House member who was going to talk with us and give us a tour of the Capitol Dome. Just then a guard, without giving a reason, yelled, “Hurry, hurry, everybody get out now!”

We all ran out as quickly as possible and found ourselves on the lawn in front of the Capitol, across the street from the Supreme Court Building, where I saw a U.S. sharpshooter on the roof. Everyone was pouring out of nearby buildings. As we saw smoke billowing out of what turned out to be the Pentagon, we started figuring out what was going on. We also learned that our hotel had also been evacuated. While most people in D.C. and those visiting have cell phones, few were working. We tried to no avail, to get a hold of loved ones to let them know that we were all physically fine, but a little shaky.

That afternoon we were supposed to have visited with Supreme Court Chief Justice William Reinquist. Instead, we were on a bus out to “no where” and finally three hours later ended up in Maryland. (Ironically, when we returned to D.C. later that day, the same ride only took approximately 25 minutes.)

Many of us that day experienced the mixed feelings of shock, sadness, confusion, and even some denial. We later heard about the plane that had crash-landed in Pennsylvania. Reports indicated that this particular plane might have been heading either for the White House or for the Capitol, if it were not for the heroism of some of the passengers on board. We possibly owed them for our safety—they were heroes; we were just lucky.

Our conference was understandably halted and because there was a moratorium on all flights from D.C. area airports, we were essentially stuck in Washington, D.C., for three additional days. There was quite a somber tone as we walked around such places as Georgetown and saw military police with rifles standing up against humvee vehicles. The city was on heightened alert yet initially President Bush wanted all activities to resume as much as possible. Partly to support this effort and to show a token defiance regarding the attacks, I even walked over to the Old Executive Office Building and took what may have been the last tour of the White House for some time to come. (Possibly in retrospect, these activities might not have been the wisest).

Needless to say, each one of us wanted to get back to California as quickly as possible. I had hardly known most of the other conference participants; it was interesting to see how each handled this emergency situation. Several parents of young children, as one could easily appreciate, were panicked because they were so far a way from their families. One recently married young man literally “felt trapped” being away from his new wife such that he kept pacing and walking around the city until he could leave. One woman, a bright executive, became so terrified and hysterical that she was willing to pay a cab driver three hundred and fifty dollars to take her on a two hour, 120 mile trip to Philadelphia so she could be near extended family. There was another woman, who prior to this flight to D.C., had not flown for thirty years because of a long standing fear of flying. Needless to say she became one of several who refused to fly home. Some rented cars when they became available. Others took the train. One couple even waited for their son-in-law to pick them up in his long haul truck. I ended up taking a plane (or in actuality, five different short flights over a twelve hour period) to eventually get back home.

On a positive note, despite the fact that the conference participants were quite different from each other, our shared, somewhat traumatic experience truly linked us together. There is now a new kind of friendship among most of the people.

I do not think the seriousness and the full sadness of what happened on September 11th completely hit me until I returned home. This leads me back to “Law and Order”. Why does a show about criminals, police detectives, and prosecuting attorneys so interest me? I think the answer is quite simple. In this time of major uncertainty with the World Trade Center disaster, Anthrax scares, and increased general anxiety, it is somewhat comforting to know that each night hardworking detectives on the side of “good” almost always apprehend the “bad” guys. If only our world situation could be so uncomplicated.

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Los Angeles Psychologist
July-August 2004

WHEN IS IT ALL RIGHT TO SAY NO?

I recently received an urgent page from a Mrs. Green, the mother of a prospective patient (the names in this article have been changed to protect privacy and conform to standards of confidentiality). She was rather agitated. She wanted her seven year old child seen right away –he was not attending school, he was withdrawn, he was pulling out some of his hair, and even slamming his body against the floor on occasion. The school nurse was apparently throwing out names of all kinds of possible disorders for this child—including Asperger’s, Autism, and Major Depression; these made the mother even more frantic. I asked Mrs. Green how long she had observed these behaviors. Except for the son’s not wanting to attend school, the other cluster of behaviors had been present for many months. As is my custom, I asked Mrs. Green who had referred her, especially since I do not see children that young. She indicated that a major managed care company had given her my name. I tried to tactfully tell her that I did not specialize in working with young children and that I would not be right for her son. She became outraged and shouted, “You are the 5th person who has said this to me. Don’t you like my insurance? Is it something I said?” Then she abruptly hung up.

This article is written as an opinion piece that I hope will generate some thoughts and further discussion. It is not meant as a comprehensive document on the subject of how to select (or reject) new patients. Some of you might want to read or re-read contracts that you have signed with various insurance/managed care organizations and/or consult with an attorney regarding a clinician’s rights and responsibilities in this matter.

While we all can empathize with the Green family, the broader issue becomes what our responsibility or obligation is regarding treating a patient who in a pre intake “interview” on the phone presents as either outside our expertise or as significantly more difficult than we can handle in light of the demands of our other patients. For instance, unless the psychologist specializes in working with borderline personality disorders, how many such patients can one reasonably have in an outpatient practice? How do you handle the situation when a severely depressed patient calls for an initial appointment and based on your brief phone contact and your prior experience, you believe that he or she should see a psychiatrist for a medication evaluation first despite the managed care company’s stating otherwise?

In informal discussions with several psychologists who have been in practice for a number of years, none seem to have a fully satisfactory answer regarding what to tell prospective patients who for whatever reason they feel uncomfortable in treating. The common response that psychologists frequently give is that their caseloads are full or that they are going away on vacation. I know one psychologist who will tell a prospective patient whom she does not want to treat that she has a 3-4 week waiting list and even then the only time available for an appointment would be around 10:00 am which is almost impossible for many working individuals or students to maintain on a regular basis. One senior psychologist told me that he simply tells the prospective patient that he “does not have the resources” to handle the issues which are being presented. One psychologist went so far as to say that for risk management issues, he would not even return the call of the most severely disturbed patient. He further stated, “If anything happens to the patient before he gets to my office, I do not want to be the one responsible”.

Obviously, for ethical reasons, I believe that it is best to be truthful with the prospective patient about why you cannot treat this person. I realize that the patient might complain to the insurance carrier about your “unwillingness” or lack of availability. It is unlikely but conceivable that with enough complaints of this type, one might be asked to resign from the panel and thus lose a referral source.
Insurance companies have to share some of the accountability for various psychologists’ being more selective in whom they choose to treat. First, with some insurance reimbursements being frozen at late 1980’s dollar amounts, there is less incentive for psychologists to want cases that most likely will require giving excessive, unreimbursed extra time (often urgent phone calls) with exceedingly tough patients and their families. Second, some insurance companies do not always reimburse in a timely manner and literally make the clinician jump through hoops to get paid. Third, despite the fact that clinicians take the time to fill out the recredentialling forms listing the types of patients (by age, disorder, or gender) that one is trained and experienced in treating, often times the insurance company will give the patient names of psychologists regardless of their specialty (or stated unwillingness to treat certain patient types). With all that the prospective patient sometimes has to go through before he or she ever gets to your office door, no wonder there is often great frustration.

What can be done to rectify these situations? Certainly, we can choose to remove ourselves from all the panels but that is not going to increase patient access to care especially those deserving individuals who on their own could not afford psychotherapy even at a reduced fee. I look forward to more LACPA members volunteering to educate and advocate for better healthcare for those in our community while working to meet the professional needs of psychologists. Further, it is hoped that LACPA members will continue to work closely with our state and national organizations to bring about necessary reforms in the healthcare insurance industry.

In case you wondered what ever happened to Mrs. Green and her son? I called her back and helped her find two excellent child psychologists who not only were on her insurance panel but were also available.

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Los Angeles Psychologist
Nov/Dec 2000

“Original ideas:
- Internet 0
- Humanity 1,000,000,000,000,000”

This was part of an intriguing advertisement that I recently came across for a company called PeopleSoft, which links corporate e-business data to employees and customers. Even the company’s name tries to downplay its emphasis on new technology.

This concept was especially of interest since one area in which I have devoted significant time this year has been in helping to establish our organization’s website and in planning how LACPA can become even more technologically advanced in the coming years. With this endeavor, I have given some thought to the impact that the new technology and the Internet have on the pace of our daily lives.

Earlier this year, I had the opportunity to attend the annual American Psychological Association’s Convention in Washington, D.C. where psychologist, noted author, professor, and management consultant Randall White, Ph.D. led a discussion on business life today. One top information technology executive stated that the corporate philosophy of the 1990’s included the phrase “Ready, aim, fire”. But in the 2000’s the pace is picking up even faster----“Fire, fire, fire” with the understanding that if the company misses one target towards a successful outcome, then the organization is bound to hit another one as long as the pace is kept fast…very fast. This philosophy was further expounded by the now popular riddle about the three frogs on the log. “If two frogs decide to jump off, how many are left?” The answer is three, because none as yet have acted on the decision.

Ms. Carly Fiorina, Hewlet-Packard’s chief executive, in the July 24, 2000 issue of Forbes, expressed her philosophy for the success of a big company, “Sharpen your vision, focus and execution. Reimagine what you can be. Work weekends.” Of course, not all companies have this philosophy but in general more individuals are working longer hours, with less time allowed for extended vacations. Overall more stress is experienced. Fun at work for many is now a distant memory. Company loyalty is a rarity with job retention a major concern for corporations today. Employees often see themselves as working on an assignment and then moving onto another project at another company.

Most of us will agree that the daily pace of our lives has picked up significantly, possibly in part by the demands of some of the newer technology. Just ask a colleague how many e-mail, he or she has to sift through upon returning from a vacation or conference or just at the end of the day. Some of my patients are truly wired for almost every eventuality—pagers, cell phones, faxes in their cars, Palm Pilot schedulers, and even digital cameras for almost instant transmissions of pictures via their computers and the Internet. Corporate life has either led the way or is reflective of this “hurry up” trend in society.
Okay, in this my last column as LACPA President, I admit it--I am guilty for moving LACPA further along in this faster paced technological age. Our organization is now getting e-mail from psychologists throughout the country and from professionals in other parts of the world. Such queries include questions about the state of our profession locally and requests for Los Angeles referrals or additional contacts.

While I have significant concern with the “speeding up” of our society (of course, we can’t totally blame the internet for that; Starbucks and other purveyors of double espressos and lattes must share some of the responsibility), this may, in actuality, prove to be an ideal time for psychologists. We hear so often about the decline of our profession, yet who better to understand the emotions, behavior, cognitions, and what motivates people than those in our profession. We must be flexible as we move towards 2001 to use our expertise to contribute to assisting our society in a number of diverse ways, some outside the traditional general office practice.As has been so well done during this year in the LA Psychologist, several different career paths or goals have been illustrated by those who have already ventured into different areas, including consulting, health psychology, geropsychology, community psychology, as well as for some, obtaining psychopharmacology training with the movement towards prescription privileges authority. There are several psychologists who are working in the area of Life Skills Training, which includes a multi-modal approach with collaboration in the areas of nutrition and exercise. As we look to the future, how will telehealth play a part and what role will psychologists have?

We need to be creative as we continue to find or maintain that special niche for success and professional satisfaction. And as we do, we need to take care of ourselves personally as well. Wayne Muller, author of Sabbath: Restoring the Sacred Rhythm of Rest, in the July 24, 2000 issue of Forbes states that while “the world is speeding up, some things aren’t built to run faster. The human heart is one of them” He further concludes, “It takes time for data to become wisdom.” As this year draws to a close and thoughts move towards holiday and family, I just wanted to take this opportunity to thank everyone within the LACPA community for allowing me the honor of serving as your President for this past year. Special thanks go to our staff, our executive administrator Patricia Fricker, our executive assistant Carol Torcello, and our PRN resource assistant Melinda Rothchild. Their steadiness and devotion keeps our organization in a positive direction. I also want to thank the Executive Committee (Helen Grusd, Jana Martin, Joe Grillo, and Diane Siegel). Their support and hours of hard work made my job so much easier. Finally, I want to thank the LACPA Board as a whole, for their commitment to psychology, our members, and to our entire community.

Take some time and have a wonderful holiday season.

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Los Angeles Psychologist
Sept/Oct 2000

TALK TO AN EXPERT, FOR $19.95

Recently, I saw a new patient, let’s call her Mrs. T., who had come in to discuss problems that she was having with her husband who, according to her, wanted sex all the time. She said that he kept quoting radio talk show hosts Howard Stern and Tom Leykis, and she was sick of this. She asked me what I thought of Dr. Laura and before I could answer, Mrs. T stated that she was a faithful Dr. Laura listener, even rattled off Dr. Laura Schlessinger’s radio phone number “1.800.DrLaura”, and in typical Dr. Laura fashion, she indicated, “I am my kid’s Mom.”

Mrs. T. wanted me to know that she was very informed about issues surrounding mental health and had even instilled this in her children. She was, however, a little concerned because her 17-year-old son was a regular viewer of MTV’s Loveline and that the host Dr. Drew was his hero. Mrs. T. went on to say that all they ever talked about was “sex, sex, sex”.

My patient also stated that she was connected to the Internet and proudly indicated that she got much of her information from that source. She said that if she had a problem, she would just log on to “Ask an Expert, Ask a Friend” http://members.aol.com/biblprof/ask-expt.htm and for the low cost of $19.95 per question, she would always get feedback and would never feel lonely again. She indicated that she knew that she could not always get help from these experts. However she stated that when she really needed more technical information she would go to Dr. Koop.com http://drkoop.com. She was, in fact, looking forward to attending a Dr. Koop sponsored support group online later that day on “stress management for parenting.”

Mrs. T was not even sure that she wanted to come to an office for psychotherapy. When I asked her why she made this first appointment, she indicated that she was tired of being on hold for Dr. Laura. In desperation, she had even tried unsuccessfully to get through to another Talk Radio host Dr. Toni Grant.
Her husband was reportedly upset that she had made the appointment. After all, he had told her that if they couldn’t work out their marital difficulties themselves, they could always “Ask Your Sex Therapist” http://www.mindspring.com/~debfox/sexask.html. For only $25 for each question, this was certainly less expensive than a psychologist office visit.

As Mrs. T. talked on and on about her total trust for these radio personalities and Internet self-helpers, I noticed that she was becoming more and more manic. Further, she revealed that at times she was very depressed. I even suggested that she might also want to see her family doctor or a psychopharmacologist for a medication evaluation. She said, “Oh, no…there is a new book called Prozac Backlash (referring to Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft, Paxil, and Other Antidepressants with Safe, Effective Alternatives by Joseph Glenmullen). I can’t take anything like that.” When I asked her what she had learned in reading this book, she indignantly said, “I didn’t actually read the book, but I know it is a best seller on Amazon.com. If I take anything, it would be Remeron because I saw this neat site on the Internet when I was searching for information on depression.” (Unfortunately, Mrs. T. may have been unaware that a pharmaceutical company had sponsored this site on depression http://www.depression-net.com.)

After she left the session, I was intrigued to find out more about some of her other Internet references. Apparently, some of these so-called authorities from “Ask an Expert, Ask a Friend” are not licensed psychotherapists. One received his master’s degree in the area of Human Resources and is in the ministry. Another loves fishing and the outdoors.

In addition, while Dr. Laura states that she is not a psychologist but a Ph.D. in Physiology with a Marriage Family Therapist license, the average listener cannot distinguish the difference. Further, when she talks, people listen. While her anti-gay position is quite disturbing, her views on the importance of family values seem to resonate with people across the country. According to RadioDigest.com, nearly 20 million people listen to her each week. Those that do listen begin to believe that all problems can be solved in 60-second sound bites. Then they question why their own psychologists aren’t helping them solve their problems as quickly.

Through the increasing popularity of talk shows and websites, which focus on mental health issues, it is obvious that the public wants more of this kind of information and related services. Paradoxically, it seems that while more people have access to information, what they often come away with is material that is either superficial or not fully understood. Chris Peck, Editor of the Spokane Spokesman-Review, in a speech given at the Pew Center for Civic Journalism Convention in August 1999, indicated that twenty-five years ago, 70 percent of adults read a newspaper regularly. Today, 51 percent read the paper regularly. Five years ago, less than one in ten American households had access to the Internet or ever went online. Today, over 50 percent of Americans have access to the Internet. Further, the number of people who sign on regularly, as in the last 7 days, is doubling each year.

Clearly, as more people are becoming Internet savvy, more and more self-help sites are being accessed, with no mandated guidelines as to their quality or to the competency of their creators. We as psychologists need to get out of our offices more, talk to the media, and in some instances become part of the new media. Further, we must be willing to take action against those who are trying to make money off of the unsuspecting consumer. As we embrace the new technologies, we also need to be the ones providing more of the information and in a manner that can be fully understood by the general public. The American Psychological Association has recently launched an excellent source of consumer related material on a wide variety of mental health related topics, everything from “Dealing with Anger” to “Nine Tasks for a Good Marriage” http://www.helping.apa.org/dotcomsense/. Now if I could only convince Mrs. T. to explore that website.

You may have wondered what finally happened to Mrs. T. I suggested that she return for a follow-up appointment the following week at 3:00PM but she declined. “I can’t do it then, Oprah’s on and next week is, How to solve your relationship problems in 5 easy steps.” Oh, well maybe another time.

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Richard Sherman, Ph.D.

The California Psychologist
September/October 2007

A Special Thing Happened on the Way to Writing this Article

In keeping with this issue’s theme of Leadership, I was planning on writing an article on the current state of health care in our country and how we need psychologists as proactive leaders to work towards crafting, advocating for, and implementing a new strong two pronged private-public healthcare system that guarantees basic medical and psychological care for all our residents. In the model that I envision, I also anticipate a dynamic primary role for psychologists including diagnosing, treating, and prescribing as well as directing programs.

However, a most interesting situation developed as I was about to write this column. I was appointed to be a member of the CA Board of Psychology. In 2003, when Governor Arnold Schwarzenegger won the recall election, I had applied for a non-paid Board appointment. This short list included the Board of Psychology. At that time, except for an acknowledgement letter, I never heard further. A few months ago, I unexpectedly received a call from an assistant appointment secretary from the Governor’s office. He asked if I still wanted to be considered for an appointment to be a member of the Board of Psychology. I was requested to update my application and participate in a phone interview shortly thereafter.

It was not until late June that I received word that I had been selected to join the Board of Psychology as a psychologist member for a three year term with the first meeting to be in early August. I accepted this appointment for which I was quite humbled and honored. Serving on the Board will afford me the opportunity to honor one of my personal and professional pledges, that of service to our communities. In this instance, I will work to protect the safety and welfare of consumers. In so doing, I will bring to the Board my unique perspective based on thirty years of experience as a psychologist and my extensive participation in and knowledge of organized psychology.

Timing of course is never perfect and my only regret was that in order to avoid even the perception of a conflict, I had to step down as your CPA President in the middle of July. The good news is that CPA is blessed with excellent, solid, and compassionate leadership. I am so pleased that Dr. Miguel Gallardo, who was President-Elect during my term and has a long history of service to CPA and APA, has now become CPA’s President. He is working with CPA’s strong team of officers-Drs. Gilbert Newman, Betsy Levine-Proctor, Sandra Harris, and Dean Haddock, a dynamic Board of Directors, an exceptional Executive Director Dr. Jo Linder-Crow, and a wonderful CPA staff.

I am so proud of what CPA accomplished during my watch, including being named outstanding state psychological association, and I will look forward to CPA’s continued growth and success. I plan to remain an active member of CPA and I look forward to seeing you at many CPA functions in the upcoming months.

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Richard Sherman, Ph.D.

The California Psychologist
March/April 2005

Confessions of a Recovering Managed Care Provider

The following was conveyed to me by a psychologist colleague, Dr. Tom W. (not his real name), who has been in private practice for over twenty-five years. He has seen his practice go from one that is primarily fee-for-service based to one largely impacted by managed care. Here are his thoughts, impressions, and trials and tribulations as he extricates himself from the influences of managed care:

I became a provider for a number of managed care organizations (MCO’s) when they first entered the California market place in the 1980’s. At the time, managed care was touted as the wave of the future. There were, in theory, several advantages for both the patient and the clinician. For the patient, there was promised easy access to qualified providers along with reasonable fees and co-pays. For the provider, the MCO marketing was akin to, “Focus on quality patient care and let us handle all the administrative functions. Moreover, for seeing patients at a ‘slightly’ reduced fee, you essentially will be guaranteed a steady stream of patients”. The hospital where I worked encouraged my participation and most of my colleagues were scrambling to sign up for as many panels as possible. The ominous side was the strong portent that if we did not sign up, eventually there would be limited access to prospective patients.

In fact, in the early 1990’s, there were several multi-disciplinary groups that were being formed and competing with one another to actually negotiate contracts with the managed care organizations. In retrospect, it seemed like the actual motto of several MCO’s was the following, “We give you the patients, we make most of the profit, and you do all the work---staffing, quality improvement, peer review, marketing, risk management, and so forth”. These were, in a sense, often clinics without walls. An incredible amount of unnecessary paperwork was generated. For instance, I would see the patient in my office, prepare a bill which was faxed to the group’s central office (usually the psychiatrist or psychologist director), then a new bill (almost identical to the first bill) would be generated which in turn was submitted to the insurance company. For all that “service”, an additional 20% was deducted from my already reduced rate!

Fortunately these multidisciplinary groups, as configured for the MCO’s, for the most part have disappeared. Still I found myself on many managed care panels. In fact, recently, I saw patients whom I thought had private insurance and later found that my reimbursement rate had been decreased because their plan was connected to some obscure MCO which still had me on the list. To make matters even more complicated, several of the smaller MCO's have merged over the years and changed names without bothering to notify the psychologist providers, even though they are, at minimum, supposed to keep current malpractice insurance and license information on file.

I rationalized remaining as an MCO panel provider for several years. I did and still do believe that I was helping patients who might otherwise not be able to receive quality mental heath care or any care, for that matter. I sensed that my clinical documentation may have improved somewhat because I knew that I might be subjected to periodic concurrent chart reviews (I was). From being a member of an MCO Peer Review Committee, I saw first hand how much emphasis the MCO placed on providing urgent and emergent care in a timely manner. (The company may have just been protecting their own interests but in a true crisis situation, clearly the patient was the beneficiary.)

But finally over the years, I have painfully learned that the concessions that the psychologist must make, and the professional denigration that one who works in the MCO setting has to endure, is just too high. There is often a contradiction in the verbiage of the MCO’s. One MCO recently wrote me and stated that one of its goals is “to help your patients remain engaged in treatment until they experience optimal benefit.” However, this is the same company that informs the patient that they have 30 visits per year (somehow there is a loop hole so these patients do not qualify for parity regardless of diagnosis). Yet, after 12 visits, the MCO often initiates the arduous process for the clinician of having to justify each additional visit. Clearly, with most MCO’s, the psychologist has to change the way he or she practices, with emphasis on referral for medication, reliance on community services, and overall reduction in intensity of care.

Further, there is the self-criticism that one may experience. While the MCO executives continue to get huge salaries and bonuses (e.g. over $12,000,000. for the head of Aetna), the psychologist is still caught in a time warp with reimbursement fees mostly frozen at 1980’s rates, which were discounted and low even then. Most managed care patients have their insurance either through their own employment or through that of a family member. While the incomes and benefits of most employees have risen over the years, these patients are often unaware of the low rate of reimbursement that the psychologist receives.

Despite the myriad of negatives, a large number of psychologists will continue to see almost exclusively managed care patients. They do this for many reasons, some noble and some because of the uncertainty of having to develop new career opportunities. Sadly, they become beholden to mega-structures that see the psychologist mostly as a provider number and as a profile on a computer screen.

So what is a psychologist to do? The path is not always clear, especially since anticipated changes in health care delivery will ultimately affect clinicians in both the private and public sectors. And as of this writing, one does not know what the Federal government might eventually propose especially in the area of more mandated health care benefits for seniors and young children.

Recently, there has been a positive thrust for psychologists to interact more and become more integrated into health care in general. This has definite benefits for the patient given that utilization of mental health services can often prevent or lessen the impact of many diseases. According to a recent article in Behavioral Healthcare Tomorrow (December 2004) entitled “A New Frontier: Psychologists Practicing in Primary Care Settings”, psychologists Reich, Romano, and Kolbasovsky indicate that primary care physicians treat nearly 75 percent of patients who are seen for depression. Further, close to 50 percent of medical patients fail to follow through on mental health referrals. This improves significantly when the behavioral health specialist is seen as part of the health care team, especially when the psychologist is “co-located” in the primary care setting.

As a profession, however, we have to be wary regarding what the insurance companies are doing as they “support” this trend towards integration of services. Aetna recently bought back its mental health division from the now bankrupt Magellan Health Services and will no longer have a major mental health carve-out company to provide services to its members. So far so good? One of the results of this change according to William Popik, MD, Aetna’s chief medical officer, as reported in amednews.com (12-27-04), is that key to the new approach will be opportunities for primary care doctors to have a greater role in diagnosing and treating patients with psychiatric/behavioral health problems. Unfortunately, Aetna appears to wants to reduce the role of psychologists and psychiatrists even further.

In his last words about his journey to recovery, Dr. W. concludes, “I am in the early post managed care phase of my professional development. I am working on creating a niche, being creative, and getting out there and letting people know what I can do…. Everything has become simplified. I no longer feel that there is a third person (the Managed Care representative) in the room when I do therapy. Less time and energy is spent on bureaucratic paperwork. Billing and getting paid is actually easier. With more time available, I happily see some low fee patients and even have more time for my family…I will keep you posted. ”

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Richard Sherman, Ph.D.
April 17, 2003
The California Psychologist
July/August 2003

ALICE IN HIPAA LAND

WARNING: The following is not intended to help the reader become HIPAA compliant. Nor is this article intended to review the multitude of HIPAA products and services that are being promoted and advertised, more and more each day. Rather this is a summary of a discussion that I had with a trusted colleague who shared her frustration in trying to prepare her individual practice for the recently implemented HIPAA rules.

I had thought that I was going to have a dialogue with Dr. Alice Sommers, (not her real name), but I quickly began to sense that I was either listening to a Dennis Miller rant or had stepped back into the upside down world of the characters in Lewis Carroll’s Alice in Wonderland.

Alice was more frustrated than I had ever seen her. She stated, “ I am HIPAAed UP. I have attended several lectures on HIPAA and I still don’t understand everything. Even the experts can’t agree. I feel like I’m at the Mad Hatter’s Tea Party with everyone arguing and nobody making any real sense. And the forms people are selling. What kind of standard is this if some Treatment Consent forms are only one page, others are three pages, and I saw one that was eight pages in length? And then we have to have a Notice of Privacy Policies and Procedures. These will add another three pages at least. How can I give my patients all these documents and expect them to read them, let alone understand them? My patients can alter or halt the agreement with me at any time but how can I explain all the ‘legalese-like terms’ such as binding, ‘in reliance’, and revocation? Some of these forms have just too many ‘thereofs’ for my comfort. There is just not enough time before, during, or after the sessions to help the patients understand all their rights, especially when these regulations are still subject to interpretation and change.” Alice was inconsolable. When I tried to mention that all we were expected to do was strive for reasonable compliance, she escalated even more. She had taken the APA online course and had tried as best she could to adopt the forms provided for her practice and to comply with California privacy laws. She did expound, “The course was pretty good but the forms were just too complicated.” She screamed out, “And when I try to simplify these forms, how do I know that I am not losing some of the important points that are supposed to be in the documents.”

Then she brought up an interesting point. Alice is trilingual. She has patients with whom she communicates in a number of languages. She yelled out, “How are my patients for whom English is not their primary language ever going to understand all of this?” as she pointed to the forms. She went on to say, “I barely understand the material myself. I just don’t have the time or knowledge to translate these into Spanish or Russian. What am I to do? I feel like I followed the rabbit down the hole—I just can’t get a handle on things—either I’m too large to get through the door or too small to reach the key.”

I tried to console Alice. But she remained distraught. “I’ve been treating patients for over twenty years. Now all of a sudden, my patients are going to come in and amend their records. Who is going to sit there with them as they review their charts and who is going to pay for that? Even with separate Psychotherapy Notes, am I going to have to pre-censor everything I want to write? I know the goal of HIPAA is to employ safeguards to protect the patient but what about us?” Again, she referred to the other Alice. “Sometimes, I am afraid that the Queen of Hearts is going to have me beheaded if I make even a small mistake.”

Again I tried to calm her but I don’t know if she was listening. I wanted her to know that Division I has a number of excellent psychologists who are well versed in HIPAA Compliance, in particular, Drs. Dean Given and Bram Fridhandler. We are also very fortunate at CPA to have someone of Dr. Charles Faltz’s caliber as Director of Professional Affairs. He has followed HIPAA and the changing regulations and interpretations from the beginning. I also wanted her to realize that even though HIPAA compliance was technically required April 14th, 2003, CPA would be sponsoring additional workshops on HIPAA and related topics to further assist members in the coming months.

Finally, at Alice’s request, I glanced at the forms she had prepared and on first review, they looked reasonable. She was relieved at my response. As we parted, I thought I heard her say in a booming loud voice, “In the words of the White Rabbit, HIP HIPAA HOORAY!!” No, I must have misheard her.

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May/June 2003

Reality TV and the New Breed of Patient

On a recent evening when I could watch only so much Iraq and terrorism coverage, I began to consider what other television “entertainment” options there might be. It quickly became obvious that traditional television has been replaced by a new breed of programming that includes a plethora of so-called reality shows, an inundation of nonstop news coverage, and a variety of self-help shows that all masquerade as entertainment. Just flip through the TV Guide for a glimpse of these new trends. One could tag along with a group as they return to their “High School Reunion;” learn from Oprah the secret to a happier life; or “Talk Back Live” on CNN’s current affairs show that solicits the opinions of its television viewers.

You might ask how this relates to a column geared for psychologists in professional practice. Stay tuned.

Our fascination with reality programs is not only coupled with our quest for entertainment but also for our search for the most up-to-date information. Most television stations cater to these demands. For instance, one local Los Angeles television station now delivers six hours of news per day. For those who have cable, CNN has two full time competitors and C-SPAN, which carries live coverage of Congress and related political events, has now grown into three different stations. And with the Internet, one can have almost instant access through “streaming” news and related information.

The trend towards our wanting to “be there” for world and life changing events started gradually with the live coverage of the events surrounding the assassination of President John F. Kennedy and has continued to the present with almost nonstop coverage of the aftermath of 9-11-01. We have seen this again most recently with the tragic loss of almost 100 people in a devastating fire at a Rhode Island nightclub. Today we also want to be “there” for less global news events. The activities of Michael Jackson, the Robert Blake case, and the disappearance of Laci Petersen, the missing pregnant woman from Modesto, CA, have captivated a large number of people who watch intently for the latest news. What this over-saturation of reality television programming allows us to see up close is raw human emotion, such as the bravery of families in light of tragedy and even the flaws of everyday people.

What does all this say about the client or patient we might see in psychotherapy? It seems undeniable that the new breed of television programming has resulted in a new breed of patient. We must be willing to address the implications of this. For one, our patients who watch any of the self-help shows are becoming increasingly “more sophisticated” in the knowledge they bring into our sessions (“Well, Dr. Phil said…”). Some may even feel more empowered to do something about the very situation that brought them into therapy. Recommended by authors on programs such as the Today Show, our patients are often more aware of the latest “lay” books on divorce, relationships, and child rearing before we are. Often even our patients who choose not to partake in the reality television frenzy are affected by the changes evident on television. For instance, there has been an increase in the pharmaceutical advertisements that target consumers directly such as with Paxil, whose slogan claims, “Your life is waiting!” Our patients may also question more. They may look you up on the Internet via Google to see if you have a website (and its quality), where you have been quoted, and what other professional activities you have pursued.

The recent inundation of news coverage also has implications for the new breed of patient. We live in a global community where communication about news events is often transmitted in seconds. Our patients are part of this larger community. They connect in ways that were not possible years ago. For some they may become quite emotional as they watch these events (such as 9-11, the war in Afghanistan, Iraq) over and over. They might become even overly invested in the sad drama of another family hundreds of miles away. Laci Peterson becomes like their sister or daughter. While many of us are still providing individual psychotherapy, we must now deal with the trend toward collective emotions—generalized anxiety, “group” depression, and traumatic stress.

All of these changes may prove challenging to the clinician who now must deal with this new breed of patient. While we may not be able to keep up with all of their knowledge of the news or of pop culture (or some of us may not even want to try), we still need to help them work through the issues that initially prompted them to seek our assistance. We want to help them explore what might be missing on a day to day basis—including meaningful relationships, family closeness, the striving for good health-both psychological and emotional, spiritual awareness, and renewed happiness, even in difficult times. As we work with these patients on these and other issues, they may even have less need to tag along with Joe Millionaire as he wines and dines women throughout Europe or traipse along the Amazon with some of the Survivors.

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December 2000

Meeting with Vice President Al Gore

I recently had the opportunity to participate in a round table discussion with Vice President Al Gore. How this came about is truly reflective of the wonderful networking and lobbying that CPA has done for so many years.

State Senator Liz Figueroa (D-Fremont) who considers CPA a very positive organization and resource recently had a bill passed which works towards increased protection of patient records and information contained in those records (Senate Bill 19). One of Vice President Gore’s themes is protecting consumers from having their confidential information released, or worse, sold to other organizations without their consent. He considers Senator Figueroa’s legislation a strong one and would like to see other states adopt California’s law.

I have learned that in politics, events can happen quickly and with little notice. On Monday Sept.18th, I received a call from John Van Etten of CPA that Liz Figueroa was going to be part of a meeting with Vice President in Los Angeles the next morning at a small school for disabled children. John asked if I or another psychologist would be able to attend.

When I arrived at the school, I quickly learned that I was part of a very small group that was meeting with the Vice President to discuss the issue of protecting patient records. This dialogue was to occur before Vice President Gore was to hold a town hall assembly on the same topic. He wanted to integrate parts of our discussion in that larger meeting. To my surprise, there were only about fifteen people at this roundtable discussion, with no cameras and no reporters. Just the Vice President and us! There were only a small number of medical people and an even smaller number of mental health professionals. While at the meeting I got the opportunity to meet again with Mrs. Sharon Davis, Governor Davis’ wife. Mrs. Davis seems very committed to the expansion of mental health services. As a matter of fact, last June, several members from the LACPA’s Governmental Affairs Committee, in collaboration with CPA, had a lobbying day in Sacramento. Through the efforts of Dr. Dana Kiesel, Chair of LACPA’s GAC, we met Mrs. Davis and discussed several of our political issues. Also in attendance was Assemblywoman Sheila Kuehl (D-41st Assembly District) of Santa Monica.

I cannot emphasize enough how important CPA’s lobbying efforts are especially in building relationships with our elected officials. Since Vice President Gore was a little late, we all were “confined” to a small classroom in anticipation of his arrival. The additional time gave us the opportunity to listen and chat with these state leaders in a way that is rarely possible. Those of you who have participated in a Lobbying Day know how precious the time we get with a legislator is.

Of course, the main event was meeting Vice President Gore who seemed genuinely interested in listening to the experiences and impressions of those in the room regarding the issue of protecting the privacy of patient records. He seemed very disturbed that information contained in patient records is apparently being sold. A woman shared how when she first became pregnant, only her physician, the lab that ran the test, and the pharmacy where she had earlier purchased a home pregnancy test knew anything related to the possible pregnancy. Yet a few weeks later, she received samples of baby bottles.
We shared with Vice President Gore that some prospective patients are afraid to even access their insurance for psychotherapy because of concern that the insurance companies will not maintain the absolute confidentiality of the material that they request in order to case manage and to process the claims. Vice President Gore responded by stating that he believed that the insurance companies are requesting too much information and when all is not received, this gives them a rationale to hold back payments. Vice President Gore seemed sincere in his comments and in his interest to gradually make reforms to the current insurance system.

In summary, this special experience with Vice President Gore and some of our state officials would not have happened without CPA members networking with our legislators. Liz Figueroa called CPA because she feels comfortable with our state association. This reaffirms the importance for all CPA members to support the lobbying efforts by our state organization. Through continued networking and lobbying, CPA’s voice will be even stronger in Sacramento.

Dr. Sherman has a private practice in Southern California and is a Member of the Board of Directors of Division I and is currently President of the Los Angeles County Psychological Association.

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Richard with Dr. Pat DeLeon, Past President of APA

Richard meets Vice President Al Gore at a Town Hall Meeting

Richard visits with psychologist-legislators at a CPA PAC Dinner

Richard meets with Governor Schwarzenegger

"Just for fun", Richard meets Rupert from the David Letterman Show.

Richard at Old Executive Office Building in Washington, D.C.

Board of Psychology Swearing in Ceremony

Richard and Insurance Commissioner Steve Poizner

Richard at KABC Radio Studio

Richard meets President George Bush

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